【作者】 邓凌；

【导师】 蔡文智；

【作者基本信息】 南方医科大学 ， 护理学， 2009， 硕士

【摘要】 预防和控制职业伤害是公共卫生领域优先研究的问题之一。虽然在全世界范围内采取了一系列的预防控制措施,但职业伤害仍然是全人群,特别是职业人群死亡和致病的主要原因之一。近些年来,国内外对于伤害的研究已渐成熟,并形成了较为系统的三级预防措施,但关于职业岗位引起的伤害研究还在不断的探索和思考当中。医院是个特殊的职业场所,它不但是预防和控制职业伤害的工作场所,同时也是受职业伤害影响的场所,医务人员(hospital staff)在医院工作过程中需要面对罹患各种疾病的患者,经常暴露于生物、化学、物理性因素等各种职业有害因素中,并处于高度紧张及心理学过度的应急状态,其所遇到的职业性危害,既有慢性长期的影响,又有急性突发性的危害。医务人员具有传染病易感者和感染源的双重身份,高强度、高风险、高应急、高投入、低产出的工作状态,生理、心理、社会等多重压力,导致医务人员职业伤害(occupalional injury,OI)流行日趋严重,这不仅损害了医务人员的身体健康,也影响了医疗卫生单位的生存与发展。然而该如何界定存在于医务人员群体中的职业伤害,因职业环境中有害因素所造成的伤害该如何防护和干预,国内外尚无一个统一的标准。直到近10余年来,不断出现的医务人员“过劳死”、医院暴力导致医务人员受伤、致残、致死等恶性事件,引起了全世界各个国家卫生行政管理官员的重视,才对医院医务人员的职业伤害给予了较为积极的关注。尽管这些年我国卫生领域的科学和技术取得了巨大进步,疾病防护方面也有卓越的成就,但值得注意的一点是,卫生医疗体系的关注仍多倾向于患者的生命维护和身体健康,而对于医务人员的身心健康却关注得很少,国内现有的众多相关研究还仅局限于职业危险因素对医务人员的伤害,更深层次的组织管理因素和个体特质等因素对职业伤害的影响很少有研究报道,并且也少有多地区、多医疗机构的联合研究。有鉴于此,为了解国内医务人员群体中发生职业伤害的流行情况,为全面分析造成医务人员职业伤害流行的深层次因素,为明确医务人员职业伤害的操作定义,界定职业伤害的高危人群,本研究对国内医务人员的职业伤害流行病学情况进行了深入的调查和研究,并获得了一些有利、有益的信息,将有助于下一步建立医务人员职业伤害防御机制提供有力而客观的依据,同时也为今后形成医务人员职业伤害评估量表建立有效的数据资源。目的基于上述的研究需要和现状,本研究拟在大规模采集影响医务人员职业伤害流行的各种资料(如人口社会学特征、组织管理环境、个人特征、职业暴露危险因素,职业损害情况等资料)的基础上,运用流行病学调查方法与统计学分析理论,综合分析引起医务人员职业伤害流行的各种危险因素,明确医务人员职业伤害类型的操作定义,筛选导致医院职业伤害发生的高危因素,锁定高危人群。本研究所获得的各种信息和资料将有助于我们下一步建立医务人员职业伤害调查量表,制定合理有效的医务人员职业防护和干预管理模式等工作的开展。方法参考国内外大量文献自行设计调查问卷,经预调查和专家咨询后确定,内容包括被调查者的一般情况、生活方式、职业危险因素表、职业伤害类型表4个部分。其中一般情况包括被调查者的人口社会学特征,如单位性质、所在科室、性别、年龄、职称、岗位、学历、工作年限等。生活方式部分包括吸烟、饮酒、饮食、睡眠、娱乐活动、排便及体育锻炼等。职业危险因素表基于现存国内医疗单位职业性质现状和美国Gimeno等学者的职业伤害调查问卷的基础上而形成,3个分表共49个条目,分别为组织管理因素(分表1)18个条目(条目1有5个子条目)、个人因素(分表2)10个条目、职业暴露因素(分表3)21个条目,基本可以涵盖国内医疗机构的职业特征情况。职业伤害类型表分为3个类型分表,即1类损伤:亚健康自评表;2类损伤:工作相关性损伤表;3类损伤:工作相关性疾病表,3个分表基本包括目前临床医务人员职业伤害现状。职业危险因素表和职业伤害类型表中的亚健康自评表均采用Likert 5级评分法进行危险程度的评估。采用多阶段分层整群抽样方法,按照不同区域、不同省市地区、不同医院等级、岗位等进行分层抽样,于2008年4月-11月对国内10560名医务人员(包括医生、护士、技术员、行政管理人员以及后勤人员等)进行现场问卷调查,调查涵盖全国华东、华北、东北、中南、西南、西北等6个区域共138家医疗机构。人员比例按照PPS抽样法(按规模大小成比例的概率抽样法),按三级医院(住院床位≥500张)100人,二级医院(住院床位100-499张)60人,一级医院(住院床位20-99张)32人的比例随机抽取调查对象。回收的调查数据经Epitada3.1数据库双人录入,核查后导入SPSS13.0统计软件进行统计学处理,将5级评分归类为2级评分(即选择“非常满意、满意”或“从来没有、几乎没有”者确定为“满意”或“无”,赋值为1分,选择“一般、不满意、非常不满意”或“有时有、经常有、一贯有”者确定为“不满意”或“有”,赋值为2分)。本研究收集的资料采用描述性分析、x~2检验、Shapiro-Wilk正态性检验,非条件多因素Logistic回归分析。结果1.共发放调查问卷10560份,回收9510份,回收率90.0%,以完整填写无缺项视为有效问卷,有效问卷9066份,有效率达95.3%。本研究完整调查127家单位包括三级医院74家,二级医院26家,一级医院27家,其中男性2823人,女性6243人,年龄17-63岁(平均32.8±8.5岁),95.4%医务人员为汉族,其余为少数民族。岗位:护理人员4263人(47.0%),医疗人员3604人(39.8%),技术人员627人(6.9%),行政管理人员212人(2.3%),后勤人员360人(4.0%);职称:初级4516人(49.8%),中级2561人(28.2%),高级(含正副高)1191人(13.1%),其他798人(8.8%)。2.调查问卷经过信度检验后得出,职业伤害危险因素表Cronbach’α系数为0.947,亚健康状态调查分表Cronbach’α系数为0.926,提示调查问卷内在一致性好,具有良好的信度。3.医务人员职业伤害情况不容乐观,根据伤害程度分为3种类型,其中,Ⅰ类伤害表现为亚健康状态,发生率为54.7%。其中轻度亚健康者为32.4%,中度亚健康者为19.5%,重度亚健康者为2.9%。前5位的亚健康状态表现是睡眠质量差,多梦、易醒(60.8%);腰酸背痛,头昏眼花(60.4%);刺激性症状,如咳嗽、流泪、喷嚏(59.0%);做事反复核对,倍感精神大不如前(58.1%);免疫力下降,容易感冒(57.5%)。4.Ⅱ类伤害为工作相关性损伤,发生率为16.53%。医务人员工作相关性损伤前10位的分别是针刺伤(49.4%)、口腔溃疡(38.4%)、切割伤(28.5%)、碰撞伤(28.5%)、月经异常(29.7%)、扭伤(20.5%)、皮肤皲裂(18.4%)、过敏性皮炎(16.8%)、皮疹(15.7%)及摔伤(14.3%)等。5.Ⅲ类伤害为工作相关性疾病,患病率为6.06%。排在前十位的医务人员工作相关性疾病分别是慢性咽炎(25.7%)、神经衰弱(22.1%)、腰颈椎病(20.9%)、慢性鼻炎(17.6%)、胃溃疡(14.3%)、下肢静脉曲张(11.4%)、抑郁症(7.5%)、听神经受损(3.1%)、腕管综合症(2.7%)、肺炎(2.7%)等。6.导致发生不同程度的医务人员职业伤害的危险因素包括:医务人员的人口社会学特征、职业环境、组织管理环境和个人特质等,具体有如下:医院等级、所处地区区域环境、岗位、职称和学历、工作时间、生活方式、组织环境、人力资源和工作负荷、安全工作环境和安全操作行为等。结论1.本次调查研究显示,发生于国内医务人员职业伤害的情况较为严重,医务人员是职业伤害的高危人群,按照伤害的程度应将医务人员职业伤害归类为3种类型,1类伤害为亚健康状态,2类伤害为工作相关性损伤,3类伤害为工作相关性疾病。2.导致医务人员职业伤害的因素是复杂而多方面的,它们彼此相互交织,共同作用,最终引起职业伤害的发生。职业伤害的危险因素包括医务人员的人口社会学特征、职业环境、组织管理环境和个人特质等,具体有如下:医院等级、所处地区区域环境、岗位、职称和学历、工作时间、生活方式、组织环境、人力资源和工作负荷、安全工作环境和安全操作行为等。提示减少各种职业危险因素对医务人员职业伤害非常重要,必须采取有效的管理方式,包括建立职业健康与安全委员会、建立有效的职业上报制度、改善生活方式、提供有效而合理的职业防护措施、满足临床合理人力资源等。3.处于亚健康状态的医务人员应引起医院管理层的重视,这类人群通过有效的健康指导和干预,能避免职业伤害的进一步加重。当员工发生工作相关性损伤时,医院相关部门应严格进行职业危险因素的有效识别和管理,加强职业危险因素的防护,减少疾病发生。当有员工发生工作相关性疾病时,医院管理部门应充分认识到职业伤害对员工的健康危害,并及时给予适当的补偿,给予人性化关怀,使工作相关性疾病所造成的伤害和损失减少到最小。4.职业伤害是一个全球性的、非常重要的公共卫生问题,而医务人员承担了维护人类生命健康和促进疾病康复的社会使命,他们的职业健康和安全问题却并未得到足够的重视。通过本次研究调查所获得的结果和信息,希望能引起相关部门的重视和关注,采取必要的防护措施,为医务人员创造良好的从业环境。下一步我们将继续加强医务人员职业伤害防护和职业健康管理机制的研究。更多还原

【Abstract】 Preventing and controlling the occupational injury issue are hot spots of field of public health research. Although a series available measures focus on this hard nut were taken all over the world, occupational injury is still a threaten to whole hospital staff. Especially it plays a key role in pathopoiesis and even more to causing death.By recent years, the research of occupational injury both domestic and abroad have got some achievements and established three-tier system of preventive measures. But there are still many works worth to be considerate. The hospital is a special place, where occupational injury happens and where we research to prevent and handle it. Hospital staff is an important part of the labor force in the society, is a wealth of knowledge and skills of the groups on the diagnosis and treatment of disease, and it is occupational health service workers to protect human health and shoulder the noble mission of saving lives. Hospital staff’s occupational hazards, consist of long-term impact of chronic, acute and unexpected hazards. Because they need to face to patients whom suffering from various diseases in the course of their work, often exposed to biological, chemical, physical factors such as occupational hazards, and psychology in a highly nervous and over-emergency status. While encountered in public health emergencies, Hospital staff needs to face and deal with the individual with the brink of jeopardy, and sometimes should? occupying in dangerous environment. Hospital staffs identity is double, with infectious diseases and infection-prone. High-intensity, high-risk, high-response, high input, low output of the job status, and multiple stress such as physiological, psychological, social et al, lead to occupational injury happening among Hospital hospital staff. This not only undermines the Hospital staff in good health, but also affects the health of the survival and development units. However, how to define occupational injury in Hospital staff, how to compensate that occupational risk factors to results in the harm, there is no a unified standard at home and abroad, and no economy reimbursement mechanism of occupational injury to Hospital staff all the more. Until nearly 10 years, some danger emerge unceasing such as Hospital staff with "Die fatigue", disability, death and other serious incidents because of the hospital violence.This led to think highly of health administration officials all over the world, and given more positive attention to occupational injuries with Hospital staff.Even though science and technology of the health has made great progress over the years in China, and disease provention has also achieved great success, but it is worth notes that, the health care system is still concerned about tending to maintain of lives and good health with patients, but concerned to Hospital staff’s health seldom, the large number of existing related research is limited to the risk factors of occupational injuries to Hospital staff, a deeper level of organizational management factors and individual characteristics and other factors on the impact of occupational injuries has rarely reported, and also rare in many areas, many medical institutions and joint research.Because of this, we conducted to penetrating study and research in order to understand the prevalence of occupational injuries in Hospital staff, comprehensive analysis deep-rooted cause of occupational injuries, defined operational definition of occupational injuries and high-risk groups. We procure some beneficial and useful information, which is helpful to set up defense reimbursement mechanism of occupational injuries to Hospital staff, and to establish an effective resource to which to form one assessment scale of occupational injury data to at the same time.Objective:Based on the above research needs, we will be to plan to collect the various kinds of information which it effected epidemic of occupational injury of medical staff (such as the sociology of population characteristics, organizational management of the environment, personal characteristics, risk factors for occupational exposure, circumstance of the occupational injuries, et al).We will use of epidemiological survey methods and statistical analysis, and comprehensive analysis factors of occupational injuries, identify definition of operation that about of occupational injuries of medical staff. We have had to screening the risk factors which led to the occupational injury of the hospital how to happened, in order to caging high-risk crowd. This study acquired information and data will help us to establish the measuring scale of occupational injury of medical staff, and to institute the mode of occupational protection and work management in the next time.Methods:We used the Multi-stage stratified cluster sampling method, and according to different regions, provinces and cities, hospital grades to stratify sampling.We have adopted a self-designed questionnaire based on previous studies, by the pre-survey and expert consultation to determine. The questionnaire have part 4,that is including the respondents in general, lifestyle, occupational risk factors, and the type of occupational injury part. Part 1: general state of health consist of the sociological characteristics of respondents, such as units of nature, the knid of department, gender, age, title, position, education, work experience and so on. Part 2 is lifestyle, including smoking, drinking, diet, sleep, recreational activities, defecation, and physical exercise. Part 3: Occupational risk factors is based on occupational status of the medical establishment and Gimeno’s questionnaire of occupational injury. They include 3 tables 49 items, there are organizational management factors (sub-table 1) 18 items (the first item has 5 sub-items), personal factors (sub-Table 2) 10 items, occupation factors (Table 3 points) 21 items. The last part that is type of occupational injury, it is divided into three types of sub-table, the first is: sub-health state self-assessment table, the second is: work-related injuries table, and third is: work-related disease table. Using Likert 5 class score method of assessment of the degree of risk. A survey was conducted from 1 May to 1 November, 2008. Hospitals in China are divided into three sizes by the number of beds (i.e., III≥500 beds, II 100-499 beds, and I 20-99 beds). To obtain a representative sample, we used multi-stage stratified cluster sampling method. First, the country was divided into six regions including Eastern, Northern, Northeastern, Middle-southern, Southwestern and Northwestern (excluding Hong Kong, Macao and Taiwan regions). Secondly, 13 level III hospitals, 5 level II, and 5 level I hospitals were separately drawn from each region according to the method of proportional allocation. In the third and last stage, 100, 50 and 30 staff members were randomly selected from the level III, II and I hospitals, respectively. All specialized hospitals (children’s hospital, women and children’s health hospital, cancer hospital and psychiatric hospital) were excluded in the evaluation program.Results:1. The subjects were 10,560 hospital staff members from a variety of disciplines (doctors, nurses, technicians, administrators, and logistics staff) working at 138 public hospitals. Our respondents were drawn from 74 Level 3 hospitals, 26 Level 2 hospitals, and 27 Level I hospitals in 26 provinces. The response rate was 90.06% (9,510 respondents). Among them, 9,066 questionnaires were used for analysis because of missing data for some of the studied variables. Hospital staff are : 2823 male, 6243 female, age include 17-63(32.8±8.5). Career: nurse-4263(47.0%), doctor-3604(39.8%), technologist-627(6.9), administrative personnel -212(2.3%), logistics staff 360(4.0%).Professional title: primary-4516(49.8%), middle level-2561(28.2%), high-grade 1-191(13.1%), others-798(8.8%).2. The reliability and validity tests showed that the risk factors of occupational injuries questionnaire’s Cronbach’αcoefficient is 0.947.Sub-health status survey meters Cronbach’a coefficient is 0.926.It suggests the questionnaire has good reliability and validity.3. Medical personnel can not be optimistic about the situation of occupational injuries, according to the degree of injury is divided into three kinds of types, of which, I -type performance for the sub-health state injuries, the incidence rate was 54.7%, and 32.4% is level lightly, 19.5% is level midrange, 2.9% is level heavy. 5 before the performance of the sub-health symptoms are poor sleep quality, many dream of, easy to wake up (60.8%); back pain, dizziness (60.4%); irritating symptoms such as coughing, crying, sneezing (59.0% ); repeatedly check things, energy diminishing (58.1%); immunity decline, easy getting cold (57.5%).4. Type 2 of injury for work-related injury, the occurrence rate of 16.24%. Hospital staff before the job-related injury were 10 needle stick injuries(49.4%), oral ulcers(38.4%), genital injuries(28.5%), collision injuries(28.5%), menstrual abnormalities(20.5%), sprains(20.5%), chapped skin(18.4%), atopic dermatitis(16.8%), skin rashes(15.7%) and fall (14.3%) and so on.5. Type 3 of injury-related occupational disease, the sick rate of 6.06%. The top 10 of the hospital staff of occupational-related diseases are chronic pharyngitis(25.7%), neurasthenia(22.1%), lumbar cervical spondylosis(20.9%), chronic rhinitis(17.6%), ulcers(14.3%), varicose veins of lower extremity(11.4%), depression(7.5%), auditory nerve damage(3.1%), carpal tunnel syndrome(2.7%), pneumonia(2.7%) and so on.6,. The medical risk factors lead to different degrees of occupational injuries include: sociology of hospital staff characteristics of population, occupational environment, organization and management of environmental and personal characteristics such as specific as follows: Levels of hospitals, and their locations, the regional environment, job, title and academic qualifications, working hours, life, environmental organizations, human resources and work load, safe working environment and safe operation of such acts.7. Medical personnel management status of occupational injury in health care management are lack of management of occupational safety and health awareness of the importance; hospital occupational injury prevention policy and improve laws and regulations, protection and monitoring facilities are not in place; the hospital staff has not yet been incorporated into the occupational injury disease management; hospital staff of occupational injury and occupational studies do not have a profound protection; there is lack of effective protection of hospital staff and occupational health professional education, guidance and management.Conclusion:1. The survey research shows that happening in the domestic hospital staff occupational injuries are more serious, medical personnel are of high risk of occupational injury, according to the degree of injury the hospital staff of occupational injury should be classified as three kinds of types, one type of injury sub-health status, 2-type of injury for work-related injury, 3 types of injury-related diseases as a career.2. Causes of occupational injury factors for medical personnel are complex and multifaceted. they are intertwined with each other, the combined effect, eventually causing the occurrence of occupational injury. Risk factors for occupational injuries, including hospital staff sociological characteristics, occupational environment, organization and management of environmental and personal characteristics such as specific as follows: Level of hospital, and their locations, the regional environment, jobs, titles and qualifications, hours of work, lifestyle, organizational environment, human resources and work load, safe working environment and safe operation of such acts. To reduce risk factors for a variety of professional medical personnel on the importance of occupational injuries, we must adopt effective methods of health management, including the establishment of the Occupational Health and Safety Commission, setting up an effective occupational reporting system to improve the way of life, providing an effective and reasonable protection of occupational to meet the clinical human resources.3. In the sub-health status of the hospital, hospital staff should be of great importance to the management of such people’s health through effective guidance and intervention to avoid further increase of occupational injury. In the event of work-related injury, strictly occupational risk factors for the effective identification and management should be taken to strengthen the protection of occupational risk factors to reduce the incidence of occupational diseases. And employment-related diseases happen, the hospital management decision-making should be fully aware of occupational injuries on the health hazards of hospital staff and the timely provision of appropriate financial compensation, given the buffer body of humanity cycle, so that employment-related disease caused by the loss of to minimize.4. Occupational injuries are a global, very important public health problem, and while medical personnel take the responsibility to ensue the human life and the health, and the promotion of the social mission of rehabilitation, their occupational health and safety issues did not get attention.5. According to the study, we hope to arouse the attention and concern from the adminstive institutions. Strengthenning management of occupational injury protection and occupational health research will be conducted in the future.更多还原